[Federal Register Volume 81, Number 185 (Friday, September 23, 2016)]
[Notices]
[Pages 65651-65653]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-23002]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4179-N]
Medicare Program; Medicare Appeals; Adjustment to the Amount in
Controversy Threshold Amounts for Calendar Year 2017
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice announces the annual adjustment in the amount in
controversy (AIC) threshold amounts for Administrative Law Judge (ALJ)
hearings and judicial review under the Medicare appeals process. The
adjustment to the AIC threshold amounts will be effective for requests
for ALJ hearings and judicial review filed on or after January 1, 2017.
The calendar year 2017 AIC threshold amounts are $160 for ALJ hearings
and $1,560 for judicial review.
DATES: Effective Date: This notice is effective on January 1, 2017.
FOR FURTHER INFORMATION CONTACT: Liz Hosna
([email protected]), (410) 786-4993.
SUPPLEMENTARY INFORMATION:
I. Background
Section 1869(b)(1)(E) of the Social Security Act (the Act), as
amended by section 521 of the Medicare, Medicaid,
[[Page 65652]]
and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA),
established the amount in controversy (AIC) threshold amounts for
Administrative Law Judge (ALJ) hearing requests and judicial review at
$100 and $1,000, respectively, for Medicare Part A and Part B appeals.
Section 940 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA), amended section 1869(b)(1)(E) of the
Act to require the AIC threshold amounts for ALJ hearings and judicial
review to be adjusted annually. The AIC threshold amounts are to be
adjusted, as of January 2005, by the percentage increase in the medical
care component of the consumer price index (CPI) for all urban
consumers (U.S. city average) for July 2003 to July of the year
preceding the year involved and rounded to the nearest multiple of $10.
Section 940(b)(2) of the MMA provided conforming amendments to apply
the AIC adjustment requirement to Medicare Part C/Medicare Advantage
(MA) appeals and certain health maintenance organization and
competitive health plan appeals. Health care prepayment plans are also
subject to MA appeals rules, including the AIC adjustment requirement.
Section 101 of the MMA provides for the application of the AIC
adjustment requirement to Medicare Part D appeals.
A. Medicare Part A and Part B Appeals
The statutory formula for the annual adjustment to the AIC
threshold amounts for ALJ hearings and judicial review of Medicare Part
A and Part B appeals, set forth at section 1869(b)(1)(E) of the Act, is
included in the applicable implementing regulations, 42 CFR 405.1006(b)
and (c). The regulations require the Secretary of the Department of
Health and Human Services (the Secretary) to publish changes to the AIC
threshold amounts in the Federal Register (Sec. 405.1006(b)(2)). In
order to be entitled to a hearing before an ALJ, a party to a
proceeding must meet the AIC requirements at Sec. 405.1006(b).
Similarly, a party must meet the AIC requirements at Sec. 405.1006(c)
at the time judicial review is requested for the court to have
jurisdiction over the appeal (Sec. 405.1136(a)).
B. Medicare Part C/MA Appeals
Section 940(b)(2) of the MMA applies the AIC adjustment requirement
to Medicare Part C appeals by amending section 1852(g)(5) of the Act.
The implementing regulations for Medicare Part C appeals are found at
42 CFR 422, subpart M. Specifically, Sec. Sec. 422.600 and 422.612
discuss the AIC threshold amounts for ALJ hearings and judicial review.
Section 422.600 grants any party to the reconsideration, except the MA
organization, who is dissatisfied with the reconsideration
determination, a right to an ALJ hearing as long as the amount
remaining in controversy after reconsideration meets the threshold
requirement established annually by the Secretary. Section 422.612
states, in part, that any party, including the MA organization, may
request judicial review if the AIC meets the threshold requirement
established annually by the Secretary.
C. Health Maintenance Organizations, Competitive Medical Plans, and
Health Care Prepayment Plans
Section 1876(c)(5)(B) of the Act states that the annual adjustment
to the AIC dollar amounts set forth in section 1869(b)(1)(E)(iii) of
the Act applies to certain beneficiary appeals within the context of
health maintenance organizations and competitive medical plans. The
applicable implementing regulations for Medicare Part C appeals are set
forth in 42 CFR 422, subpart M and apply to these appeals. The Medicare
Part C appeals rules also apply to health care prepayment plan appeals.
D. Medicare Part D (Prescription Drug Plan) Appeals
The annually adjusted AIC threshold amounts for ALJ hearings and
judicial review that apply to Medicare Parts A, B, and C appeals also
apply to Medicare Part D appeals. Section 101 of the MMA added section
1860D-4(h)(1) of the Act regarding Part D appeals. This statutory
provision requires a prescription drug plan sponsor to meet the
requirements set forth in sections 1852(g)(4) and (g)(5) of the Act, in
a similar manner as MA organizations. As noted previously, the annually
adjusted AIC threshold requirement was added to section 1852(g)(5) of
the Act by section 940(b)(2)(A) of the MMA. The implementing
regulations for Medicare Part D appeals can be found at 42 CFR 423,
subparts M and U. The regulations at Sec. 423.562(c) prescribe that,
unless the Part D appeals rules provide otherwise, the Part C appeals
rules (including the annually adjusted AIC threshold amount) apply to
Part D appeals to the extent they are appropriate. More specifically,
Sec. Sec. 423.1970 and 423.1976 of the Part D appeals rules discuss
the AIC threshold amounts for ALJ hearings and judicial review. Section
423.1970(a) grants a Part D enrollee, who is dissatisfied with the
independent review entity (IRE) reconsideration determination, a right
to an ALJ hearing if the amount remaining in controversy after the IRE
reconsideration meets the threshold amount established annually by the
Secretary. Sections 423.1976(a) and (b) allow a Part D enrollee to
request judicial review of an ALJ or Medicare Appeals Council (MAC)
decision if, in part, the AIC meets the threshold amount established
annually by the Secretary.
II. Provisions of the Notice--Annual AIC Adjustments
A. AIC Adjustment Formula and AIC Adjustments
As previously noted, section 940 of the MMA requires that the AIC
threshold amounts be adjusted annually, beginning in January 2005, by
the percentage increase in the medical care component of the CPI for
all urban consumers (U.S. city average) for July 2003 to July of the
year preceding the year involved and rounded to the nearest multiple of
$10.
B. Calendar Year 2017
The AIC threshold amount for ALJ hearing requests will rise to $160
and the AIC threshold amount for judicial review will rise to $1,560
for CY 2017. These amounts are based on the 56.110 percent increase in
the medical care component of the CPI, which was at 297.600 in July
2003 and rose to 464.582 in July 2016. The AIC threshold amount for ALJ
hearing requests changes to $156.11 based on the 56.110 percent
increase over the initial threshold amount of $100 established in 2003.
In accordance with section 1869(b)(1)(E)(iii) of the Act, the adjusted
threshold amounts are rounded to the nearest multiple of $10.
Therefore, the CY 2017 AIC threshold amount for ALJ hearings is
$160.00. The AIC threshold amount for judicial review changes to
$1561.10 based on the 56.110 percent increase over the initial
threshold amount of $1,000. This amount was rounded to the nearest
multiple of $10, resulting in the CY 2017 AIC threshold amount of
$1,560.00 for judicial review.
C. Summary Table of Adjustments in the AIC Threshold Amounts
In the following table we list the CYs 2013 through 2017 threshold
amounts.
[[Page 65653]]
----------------------------------------------------------------------------------------------------------------
CY 2013 CY 2014 CY 2015 CY 2016 CY 2017
----------------------------------------------------------------------------------------------------------------
ALJ Hearing..................... $140 $140 $150 $150 $160
Judicial Review................. 1,400 1,430 1,460 1,500 1,560
----------------------------------------------------------------------------------------------------------------
III. Collection of Information Requirements
This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).
Dated: September 7, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2016-23002 Filed 9-22-16; 8:45 am]
BILLING CODE 4120-01-P